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ISSN 0008-3194 (p)/ISSN 1715-6181 (e)/2014/170183/$2.

00/JCCA 2014

The origin, and application of somatosensory


evoked potentials as a neurophysiological
technique to investigate neuroplasticity
Steven R. Passmore, DC, PhD1,2,3,4
Bernadette Murphy, DC, PhD4
Timothy D. Lee, PhD1

Somatosensory evoked potentionals (SEPs) can be used


to elucidate differences in cortical activity associated
with a spinal manipulation (SM) intervention. The
purpose of this narrative review is to overview the
origin and application of SEPs, a neurophysiological
technique to investigate neuroplasticity. Summaries
of: 1) parameters for SEP generation and waveform
recording; 2) SEP peak nomenclature, interpretation and
generators; 3) peaks pertaining to tactile information
processing (relevant to both chiropractic and other
manual therapies); 4) utilization and application of
SEPs; 5) SEPs concurrent with an experimental task and
at baseline/control/pretest; 6) SEPs pain studies; and
7) SEPs design (pre/post) and neural reorganization/
neuroplasticity; and 8) SEPs and future chiropractic

Les potentiels voqus somesthsiques (PES) peuvent


servir lucider les diffrences dans lactivit
corticale lie une manipulation vertbrale (MV).
La prsente revue narrative a pour objet de donner
un aperu de lorigine et de lapplication des PES,
une technique neurophysiologique servant tudier
la neuroplasticit. Les sujets suivants feront lobjet de
rsums: 1) paramtres pour la gnration de PES et
lenregistrement des formes dondes; 2) nomenclature,
interprtation et gnrateurs du point maximum de
PES; 3) points maximums relatifs au traitement de
linformation tactile (pertinent pour la chiropratique
et les autres thrapies manuelles); 4) lutilisation et
lapplication des PES; 5) PES en mme temps quune
tche exprimentale et au point de rfrence/prtest;
6) les PES et les tudes sur la douleur; 7) conception
des PES (pr/post) et rorganisation neuronale/
neuroplasticit; 8) les PES et la recherche future en
chiropratique. Comprendre ce que sont les PES ainsi

McMaster University
University of Manitoba
3
New York Chiropractic College
4
University of Ontario, Institute of Technology
1
2

Corresponding Author Address: Steven Passmore, School of Medical Rehabilitation, University of Manitoba,
R106-771 McDermot Avenue, Winnipeg, Manitoba, Canada, R3E 0T6
e-mail: passmore@cc.umanitoba.ca
telephone: (204) 787-1899
JCCA 2014
170

J Can Chiropr Assoc 2014; 58(2)

SR Passmore, B Murphy, TD Lee

research are all reviewed. Understanding what SEPs


are, and their application allows chiropractors,
educators, and other manual therapists interested in SM
to understand the context, and importance of research
findings from SM studies that involve SEPs.

que leur application permet aux chiropraticiens, aux


ducateurs et aux autres thrapeutes manuels qui
sintressent la MV de comprendre le contexte et
limportance des conclusions des recherches sur la MV
o lon a recours aux PES.

(JCCA 2014;58(2):170-183)

(JCCA 2014;58(2):170-183)

k e y w o r d s : somatosensory evoked potential,


neuroplasticity, manipulation, chiropractic

m o t s c l s : potentiel voqu somesthsique,


neuroplasticit, manipulation, chiropratique

Introduction
Evoking and recording somatosensory evoked potentials
(SEPs) is appearing in scientific literature that pertains to
spinal manipulation (SM). There is evidence to support
that SEPs are a neurophysiological technique capable of
elucidating differences in cortical activity associated with
an SM intervention.1,2 Haavik and Murphy3 hypothesized
that appropriate spinal movement normalizes afferent
input and restores sensorimotor function and integration
by filtering and processing appropriate somatosensory
input. The purpose of this manuscript is to provide an
overview of the origin, and application of somatosensory
evoked potentials as a neurophysiological technique to
investigate neuroplasticity. Neuroplasticity is defined as
how ones central nervous system adapts to their everchanging environment. Neuroplastic changes can be subjectively positive for the individual (adaptive) such as
learning, or they can be subjectively negative (maladaptive) such as pain.3 Understanding what the SEPs technique is, and how it has been applied will allow chiropractors, manual therapists and educators with an interest
in SM to better understand the context, and importance of
research findings from SM studies that involve SEPs as an
outcome measure.
The most basic form of electrical communication between cells in the human body is the action potential.4 A
neuron, stimulated by other cells or other external stimuli,
will reach a point at which an all or none burst of electricity is generated, and propagated. Depending on the type
of neuron where this propagation is generated the result
will be either inhibitory, or excitatory in nature at the synapse where it terminates. Excitatory post synaptic potentials facilitate action potential generation at the cells upon

which they synapse. Such changes in electrical activity


occur as a result of positive and negative ions crossing
the cellular membrane. The ion flow results in changing
regional polarity, and the resulting voltage changes in the
area can be measured to demonstrate activity in the brain.
The brain is the site of integration, and perception of all
external and internal stimuli, it is the keystone of the central nervous system. The somatosensory system is comprised of elements of the peripheral nervous system and
central nervous system that serve the modalities of touch,
vibration, temperature, pain and kinesthesia.5 Neurologically this pathway consists of peripheral receptors and afferent neurons that enter the dorsal root ganglion prior
to ascending the spinal cord to the medulla where they
synapse with the ipsilateral dorsal column nuclei (Figure
1). Once in the medulla they cross to the contralateral side
of the brain (decussate) and the pathway continues to the
contralateral ventral posterior lateral nucleus of the thalamus prior arrival at the primary somatosensory cortex
for processing.6 This pathway consists of the dorsal column medial lemniscal, and thalamo cortical sensory
systems.7 Knowledge of the anatomical pathway of afferent and subsequently perceptual information can serve
as a roadmap to the study of information acquisition and
processing.

J Can Chiropr Assoc 2014; 58(2)

Origins of Somatosensory Evoked Potentials


An evoked potential occurs when the stimulation of sensory receptors or afferent nerve bundles past their resting threshold results in the generation of a compound
action potential. While not mutually exclusive the evocative stimulation can consist of tactile, vibrational, painful
or electrical elements.8 The compound action potential
171

Somatosensory Evoked Potentials

Figure 1.
Dosal column-medial lemniscal pathway.

transmitted can be recorded using electrodes to study the


post-stimulus characteristics.9 Potentials evoked by peripheral nerve stimulation can be recorded in the sensorimotor cortex and multiple other sites along the pathway.10
A somatosensory evoked potential (SEP) is the electrical activity response measured at the skins surface following controlled peripheral nerve stimulation. Electrical
activity from peripheral stimulation measured over the
scalp reflects cerebral action potentials and are best recorded contralateral to peripheral nerve stimulation.11 The
recorded electrical potential of this afferent volley bombardment generates a complex waveform.12
Waveform reproducibility is confirmed by taking the
average of several controlled stimuli to waveform generation time-locked trials. The resulting average waveform
can then be analysed in terms of the peaks and troughs
172

present at different time points relative to the stimulation.


To understand the significance of the waveforms, their
components and their neurological interpretation, Giblin13
observed SEPs in both healthy participants and patients
with impairments including lesions of the peripheral
nerves, spinal cord, and the brain. He described early
potentials as those of brief duration that occur within the
first 35 msec after stimulation of the median nerve at the
wrist. Recorded latency will vary based on the distance
from anatomical stimulation site. For example, lower extremity potentials have a slightly longer latency than upper extremity potentials as they have a longer distance to
travel. Early potentials were accurately reproducible and
Giblin13 noted the positive and negative voltage changes
at particular times in milliseconds.
Early SEP studies had substantial variability in many
J Can Chiropr Assoc 2014; 58(2)

SR Passmore, B Murphy, TD Lee

facets of technique application. This variability included,


but was not limited to: the stimulus intensity and interstimulus interval of the peripheral evoked potentials, the
impedance and location of recording electrodes, the number of signals recorded to generate an average waveform,
the filtering and amplification of recorded signals, and the
measurement and recognition of specific peaks. Acknowledging this heterogeneity of method, but the usefulness
of this approach to the study of the nervous system, the
International Federation of Clinical Neurophysiology
(IFCN) generated a report from a committee of recommended standards for short latency somatosensory evoked
potentials.14 The findings from the report have been used
in part to generate suggested SEP stimulating and recording parameters as detailed in the following section of this
manuscript. A brief overview comparisson of SEPs and
other common neurological recording techniques can be
found in Table 1.
Parameters for SEP generation & recording of
waveforms
Different from electroencephalography (EEG) which reflects the brains spontaneous electrical activity over a
short period of time, SEPs are not recorded continuously
to spontaneous stimuli but are time locked to a stimulus
with a pretrigger.15 SEP peak amplitudes are traditionally
in the under 10V range (smaller then EEG [tens of V],
EMG [mV], ECG [V]).15 The stimulation most favoured
is electrical stimulation as it has parameters that are easily
manipulated and controlled.16
According the updated IFCN guidelines17 the recommended electrical stimulus should consist of a 0.1-0.2 ms
duration square wave pulse. These pulses can be delivered
by constant current stimulators applied transcutaneously
over the targeted nerve. When stimulating a mixed (motor and sensory fibre containing) nerve, stimulus intensity
should exceed the motor threshold for eliciting a muscle
twitch. But, the intensity should not be so high as to excite
a-delta or c-fibres that are excited by nociceptive input.
Gandevia and colleagues18,19 have demonstrated that
muscle afferents most likely dominate the cerebral potentials produced by stimulation of the mixed median nerve
at the wrist. IFCN guidelines recommend that the pulse
delivery should repeat at a frequency between 3 and 5 Hz.
Stimulation frequencies up to 8 Hz can be used for pulse
delivery if the latency of a target peak to be measured ocJ Can Chiropr Assoc 2014; 58(2)

Figure 2.
Relevant 10-20 system electrode placement sites.

curs before 30 ms. After 30 ms peaks resulting from this


higher (8hz) frequency of stimulation are subject to reduction or attenuation which is why a bandwidth of 3-5Hz
is preferred.20 Recently however, Haavik and Murphy21,
have demonstrated that stimulation rate may impact early
peaks differentially. Specifically, a rate of 5 Hz enhanced
the N24 SEP peak amplitude, while a rate of less than
3 Hz was needed to reliably record the N30 peak. Electrodes for stimulation should be placed over the course of
the desired nerve, with the cathode placed 2 cm proximal
to the anode.17
To most effectively, and efficiently record SEPs signals
to measure the changing activity in the brain and central
nervous system, it is recommended that one centimetre
surface recording EEG electrodes should be placed as per
the 10-20 international EEG system (Figure 2).15 The cortical locations that should be used contralateral to the site
of stimulation are the Fc (contralateral frontal) and Pc
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Somatosensory Evoked Potentials

Table 1.
Neurological imaging and measurement techniques
Technique

Role of Technique

Advantages

Limitations

Positron
Emission
Tomography
(PET)

Three-dimensional functional
imaging of a radioactive tracer
(injected the body).

Reasonable spatial
resolution.

Requires injection of radionucleotide,


expensive (require full time staff
& radionucleotide cost), restricted
movement environment, not portable.

Functional
Magnetic
Resonance
Imaging (fMRI)

Measure three-dimensional changes


in cerebral blood flow overlaid on a
magnetic resonance imaging brain
map.

High spatial resolution.

Expensive (require full time staff),


restricted movement environment, not
portable. Reliant upon neurovascular
coupling, which is the interpretation
of the blood oxygen level dependent
(BOLD) signal. Low temporal resolution.

Transcranial
Magnetic
Stimulation
(TMS)

Sends a magnetic burst targeted


toward a general anatomic region.

Non-invasive, can be used


to elicit motor evoked
potentials (MEPs) with
measurable amplitude
and latency using surface
electromyography (EMG).

Requires high level of training to


deliver, and interpret. Variability can
be high depending on relative positions
of coil, and participant. Low spatial
resolution.

MagnetoMeasures magnetic fields from


encephalography cerebral sources.
(MEG)

High temporal resolution.

Expensive (require full time staff),


requires high level of training to deliver,
and interpret, restricted movement
environment, not portable.

ElectroRecords spontaneous electrical


encephalography activity from the central nervous
Surface (EEG) system relative to a reference
electrode.

High temporal resolution,


records electrical
responses concurrently
with presentation of other
stimuli.

Requires high level of training to


deliver, and interpret. Surface recorded,
and not time locked to external precognitive stimuli, spatial resolution
limited.

Somatosensory
Evoked
Potentials
Short Latency
(SEPs)

Responses of PNS and CNS to time


locked and consistent stimulation
producing electrical activity as
consistent measureable waveforms
that can be averaged for clean
interpretation. Measured using
surface EEG.

Time locked to stimulus


(consistent), early peaks are
pre-cognitive in response to
stimulation.

Requires high level of training to


deliver, and interpret. Surface recorded,
spatial resolution limited to peak
interpretation.

Event Related
Potentials
(ERPs)

Brain response directly related to a


High temporal resolution
sensory, motor or cognitive event.
(<1 ms)
Waveforms are averaged by repeated
exposure to the event or stimuli of
interest. Measured using surface EEG.

Source
Localization

Mathematical model for data deconvolution, allows for de-blurring


of scalp EEG.

Standardized
Mathematical model used to
Weighted Lowdetermine the depth of source
Resolution Brain localization of EEG signals.
Electromagnetic
Tomography
(swLORETA)
174

Poorly defined spatial resolution.


Requires high level of training to
deliver, and interpret.

Improves EEG spatial


Requires high level of level of training
resolution from a
to deliver, and interpret
centimetre scale on the
cortex to a millimetre scale.
Improves EEG and Source
Localization interpretation.

Requires high level of level of training


to deliver, and interpret.

J Can Chiropr Assoc 2014; 58(2)

SR Passmore, B Murphy, TD Lee

(contralateral parietal).17 Skin at the scalp EEG electrodes


should have less than 5 Kohms impedance. The number
of waveforms that need to be averaged are from between
500 and 2000 stimuli presentations, in order to clearly
differentiate the signal from noise. Updated IFCN guidelines17 recommend a filtering bandwidth with a high pass
of 3 Hz and low pass of over 2000 Hz to isolate reproducible waves from background noise. Scalp electrodes
may utilize an earlobe reference17 and a lip placement for
the ground electrode22. Adherence to these recommendations will allow the optimal uniform technical recording
environment to assess the neurophysiological changes
associated with behavioural or perceptual experimental
interventions and the resulting information processing.
SEP peak nomenclature, interpretation and
generators
Waveform peaks are assigned a letter representing their
polarity (positive or negative). By convention an upward
wave deflection is a negative polarity (N), while a downward deflection is positive (P), and also assigned an integer based on the post stimulus latency (in ms) at which
they appear in a healthy population.17 Both the latency
and the amplitude (uV) of these peaks can be used to
interpret changes in neural activity. The amplitudes and
latencies of the peaks are thought to represent a combination of the peripheral and central nervous system reception of the external stimulus, and the early processing
by a given neural structure of that stimulus. Specifically,
amplitude represents the magnitude of the incoming afferent volley.15 Latency reflects the anatomical location
along the somatosensory pathway impacted by the peripheral stimulus.15
The waveform is a post-stimulation cortical-electrical potential with predictable and reproducible peak and
trough amplitudes and latencies based on recording site.
The signals recorded are reflective of their neural generators.17 The neural generator can be near-field, or anatomically close to the electrode (cortex surface), or farfield, relatively anatomically distant (subcortical).6 This
means that the near-field potentials represent the direct
region of polarity change proximal to the electrode. Farfield potential responses reflect structures with a diffuse
signal to a larger area of the surface, they are more likely
to be detected at multiple electrode sites.15
Early SEP peaks also referred to as short latency
J Can Chiropr Assoc 2014; 58(2)

SEPs are considered to be the most useful for the study of


neurological activity as they are the least variable among
participants with intact nervous systems free from pathology considered to represent the normal population.15 Short
latency refers to the peaks and troughs present within the
first 40 msec following a single stimulation to the upper
limb, and less than 50 msec for the lower limb.23 Peaks of
longer latency than 45 ms may be susceptible to cognitive
factors, which may further increase their variability.17
Identification and meaning associated with specific
temporal peaks have been derived from several different methodologies. One methodological example are the
techniques used in laboratory obliteration studies which
are traditionally performed with animal populations.
Severe attenuation or abolishment of all SEPs occurs in
primates when the dorsal columns of the upper thoracic,
or mid cervical aspects of the spinal cord are ablated.24
No SEP anomalies occur when there are lesions to other
parts of the spinal cord but the dorsal columns are left
intact. This finding suggests the dorsal column tracts are
essential in the mediation of SEPs.16 Additionally, SEP
peaks have been shown to result mainly from stimulation
of large myelinated sensory afferents such as 1a muscle
afferents and, possibly, cutaneous afferents.18,19 The low
intensity of stimulation applied, which is just above motor
threshold, means that large myelinated sensory afferents
which are also the most rapidly conducting afferents are
preferentially excited, and reach the cortex prior to other
afferent fibres.
The presence of a specific pathology is another factor that impacts SEP peak amplitude, latency or total
absence. Peaks may be delayed or absent in pathology
cases with an etiology that is degenerative, traumatic or
congenital.16 Degenerative pathologies such as multiple
sclerosis (MS)25,26,27,28, spinal cord tumours affecting the
posterior columns29 amyotrophic lateral sclerosis (ALS),
Freidrichs ataxia30,31 and Guillain-Barr Syndrome32 will
alter SEP waveforms. Traumatic or compressive pathologies including focal nerve lesions33,34, brachial plexus lesions/nerve root avulsion35,36,37, meralgia paresthetica34,
or nervous system lesions from a traumatic brain injury
(TBI)38 or surgery16 are visible in the presence or absence
of SEP components. Congenital pathology such as achondroplasia with associated foramen magnum stenosis will
yield an abnormal SEP study.39 SEPs can even be used
to conclusively identify brain death. A peak at N13/N14
175

Somatosensory Evoked Potentials

Figure 3.
Typical SEPs waveform.

with no peaks of further latency indicate that signals are


reaching the cervical spine close to the medulla, but with
no cerebral activity.16
It is possible to identify many SEP peaks, their origin, and significance (Figure 3). For the purpose of brevity, this review will focus on the origin of the P14-N18
complex for N18, N20-P27 complex for N20, P22-N24
complex for N24, and P22-N30 complex for N30. These
peaks have different possible implications for the study
of tactile information processing (N1840; N2041; N2442;
N3043). Tactile information processing is particularly relevant in the study of chiropractic and other manual therapies. Clinicians use their tactile sense to both assess (ex.
joint and muscle palpation) and treat patients. Patients
receive tactile input (ex. manipulative thrust, soft tissue
mobilization) delivered with therapeutic intent from the
clinician.
The N18 Peak
The far field, widespread, N18 component is distinct in
SEP traces. It has the broadest elevation from baseline
following the P13-14 potential.44 Mauguiere15 suggested
that there are multiple generators of the N18 scalp-recorded potential. Clinical evidence indicates that the N18
component is generated in the brain stem at the level of
the midbrain-pontine region.45 Such brainstem lesions significantly attenuate the N18 amplitude.45 Noel, Ozaki and
Desmedt46 suggested that the N18 peak originates in the
176

lower medulla nuclei including the accessory inferior olives and dorsal column nuclei. Noel, Ozaki and Desmedt46
presented three patients whose N18 component remained
intact although they had lesions at the medial lemniscus
levels including the midbrain and upper medulla. The
finding that N18 is related to the dorsal column nuclei is
also supported by Manzano, Negrao and Nobrega47 who
found N18 as the only SEP component resistant to tactile cutaneous vibratory changes. Sonoo, Sakuta, Shimpo,
Genba, and Mannen48, and later Sonoo et al.49 concluded
that the cuneate nucleus was likely responsible for the
N18 potential based on several observed cases of patients with deep sensation disturbance and high cervical
brain stem, thalamic, and pontine lesions. A review by
Sonoo50 expanded on the mechanism for the N18 peak.
He concluded it is likely generated in the cuneate nuclei
through primary afferent depolarization. Specifically, by
collaterals from dorsal column afferents to cuneate nuclei
interneurons that synapse on dorsal column fibers presynaptic terminals that become depolarized and function
as presynaptic inhibition.50
The N20 Peak
The primary somatosensory cortex lies in the posterior
bank of the rolandic fissure representing Brodmanns
area 3b in the parietal lobe. This is the site of N20 peak
generation.51 It is known to respond to contralateral tactile stimuli.52 The parietal N20 peak is consistent and occurs contralateral to the site of stimulation.15 Brodmanns
area 3b (the primary somatosensory cortex) responds to
cutaneous inputs, but not joint movement input. Desmedt
and Osaki53 confirmed this N20 cutaneous response, and
not joint movement, in a study on passive finger movement. In healthy normal participants the N20 peak is the
earliest cortical processing in the primary somatosensory
cortex.
The N24 peak
The origin of peak N24 is located close to the location
of N20. N24 is a frontal lobe negativity that appears on
the ascending slope of peak N30. Garcia Larrea, Bastuji and Mauguiere54 found that N24 is best revealed at
higher stimulus rates (greater than 3 Hz) that selectively
decrease the N30 peak. As discussed previously in this
review, Haavik and Murphy21 have recently shown that
5 Hz stimulation is sufficient to enhance the N24 recordJ Can Chiropr Assoc 2014; 58(2)

SR Passmore, B Murphy, TD Lee

ing while ensuring detection of changes subsequent to a


motor training task. Due to its mild variability in latency
the N24 peak has also been referred to as N2355, or N2543.
Waberski et al.43 used source localization to identify to the
posterior wall of the central sulcus in area 3b of the somatosensory cortex as the site of N24 generation. In order
for this pathway to continue the input sent to the somatosensory cortex travels through the cerebellar cortex and
deep cerebellar nuclei.56 The N24 amplitude is enhanced
if the cerebellar cortex is disrupted. N24 is reduced or absent, but all preceding peaks are left intact if the cerebellar cortex and deep cerebellar nuclei are lesioned.42 The
characteristics of N24 are linked directly to the integrity
of the cerebellum through its cortex and its deep nuclei.
In summary, when a deep structure is lesioned the peak
is obliterated, while if only the cortex is disrupted the
peak is enhanced. The aforementioned findings provide
evidence of the possibility that the deep structures generate increased activity in an attempt to relay signals to the
cortex in the event that the cortex is damaged and fails to
appropriately received signals.
The N30 Peak
The N30 frontal lobe peak reflects sensory integration.57
This peak is negatively impacted by imagined or actual
voluntary muscle contraction. Cheron and Borenstein55
demonstrated that both imagined and actual finger movements attenuated the N30 peak. As a result this peak is
believed to reflect complex cortical and subcortical loops
that link the basal ganglia, thalamus, pre-motor areas,
and primary motor cortex.58-61 Parkinsons disease (PD)
is known to degrade components of the basal ganglia,
including but not limited to the internal globus pallidus,
and the subthalamic nucleus. A PD patient population has
demonstrated a decreased N30 peak compared to a control
population.62,63 Muscle tone rigidity decreases and N30
amplitude increases in PD patients when the neuromuscular junction is blocked.63 Basal ganglia deep brain stimulation also produces increased N30 amplitude, which is
attributed to improved supplementary motor area (SMA)
activity.62 Basal ganglia efferents are anatomically found
to terminate in the ventrolateral thalamus, from where
they project to the SMA.64,65 Waberski et al.43 employed a
mathematical technique known as source localisation to
suggest that primary motor cortex or more specifically the
pre-central motor cortex is the N30 peak generator. PriJ Can Chiropr Assoc 2014; 58(2)

mate66,67, and subsequently human68 intracortical recordings support that N30 is generated at the motor cortex.
The neural generators of the N30 SEP peak have recently been explored using novel technology. Cebolla,
Palmero-Soler, and Cheron69 used swLORETA (standardized weighted Low Resolution Brain Electromagnetic
Tomography) and determined that the N30 is generated
by network activity in the motor, premotor and prefrontal
cortex. This finding sheds light on the role N30 plays as a
marker of neural processing relevant to sensorimotor integration. The role of the prefrontal cortex is a finding of
particular interest since it is a site of executive function
including cognitive planning and decision-making. The
prefrontal cortex receives somatosensory input and other
internal and external sources of information that can be
used to inform decision- making. Clinicians who deliver
manual therapies use their tactile sense via palpation of
muscles and joints to make clinical decisions.
Utilization and Application of SEPs
Clinical
SEP recording is an objective technique and is often more
sensitive than the traditional neurological component of
physical examination.7 For example, SEPs can be used
in comatose, anesthetised patients.7 Interpretation of the
presence and absence of specific waveforms can be utilized to predict comatose patient prognosis. When SEPs
are recorded within 72 hours of entering the comatose
state prediction of prognosis is >99% accurate.70
Based on the reliability of SEP peaks, it is increasingly
accepted for use in the operating room. Operating room
monitoring of SEP peaks is done to correct spinal cord
ischaemia, prior to it becoming a debilitating issue. SEPs
are used in repetition to continuously monitor for detection of neurological impairment during scoliosis surgery.
This technique has resulted in a 50-60% decrease in paraplegia post surgery.71
Surface recording electrodes, while relatively non invasive, cause the spatial accuracy of SEP recording to be
decreased compared to other direct neuromeasurement
techniques. SEPs are regarded as having high temporal
and low spatial resolution.72 The meaningfulness of the interpretation of SEP waveforms is established enough that
is has been used as a pre-screening tool for inclusion or
exclusion of participants in scientific research. SEPs were
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Somatosensory Evoked Potentials

collected prior to selection for experimental inclusion in


a traumatic brain injury (TBI) study by Sarno, Erasmu,
Lipp and Schlaegel.38 This technique allowed the reduction and refinement of a pool of participants for a reaction
time study. Understanding limitations and performance of
a TBI population can otherwise be problematic to test due
to the possible heterogeneity of symptoms. Examination
of the quality of the N20 peak allowed the exclusion of
participants with severe sensory impairment, thus yielding an objective test to produce a more homogenous experimental group. SEPs may be used as a neurophysiological outcome measure when behavioural findings are
absent (clinically silent).16 Whether or not SEPs also have
the potential to reveal clinically silent musculoskeletal lesions is an area that requires further research.
SEPs Concurrent with an Experimental Task and at
Baseline/Control/Pretest
Buchner et al.41 measured immediate cortical plasticity related to attention and anesthesia. They first elicited SEPs
at base line, then again concurrent with conditions of
directed attention. They found that an immediate cortical
reorganization occurs at peak N20 when partial deafferentation was present. They used an electrical stimulation
attention task on fingers 1, 3 and 5. Temporary deafferentation was achieved via injection of 1.5-2 ml of a 2%
Meaverin solution to digits 2-4. They found that when
participants were anesthetized directed attention to the
dorsal hand increased the accessibility of neighboring
cortical areas. Waberski, Gobbele, and Buchner73 found
similar results before and during air puff stimulation of
the anesthetised thumb. Cortical representation of the
thumb decreased in the presence of anesthesia compared
to a preanesthetic condition. They interpreted this finding
to indicate that anesthesia yields an immediate cortical
reorganization of the representation of the affected and
adjacent digits. From a clinical perspective even an acute
peripheral injury or sensory perturbation may cause immediate cortical reorganization measurable using SEPs.
Psychophysical literature that pertains to tactile stimulation raises concerns regarding the generation and recording of SEPs concurrent with perception or performance related to another task. It is possible that concurrent SEPs stimulation could negatively impact accurate
performance when responding to multiple tactile stimuli,
or distractors, leading to unintended masking or enhance178

ment. For example Giblin13 determined that SEP peaks


are attenuated or masked in the presence of additional tactile stimulation meant to be irrelevant to SEPs technique
recording. The phenomenon is now known as sensory
gating. Morita, Petersen, and Nielsen74, cautioned that
SEPs gating can occur with concurrent motor activation
in the lower extremity.
When designing a movement study with concurrent
SEPs recording, experimentors need to be aware that factors leading to gating can result in the decreased amplitude of an expected waveform signal. For example, in as
few as 60 ms post contraction tibial nerve SEPs would
become attenuated when either foot was plantar or dorsi flexed concurrent with SEPs recording. In as few as
60 ms post contraction tibial nerve SEPs would become
attenuated when either foot was plantar or dorsi flexed
concurrent with SEPs recording.74 If such factors are not
controlled for the misinterpretation of results is possible.
SEPs Pain Studies
Tinazzi et al.75 explored the impact of tactile sensory disruption using a passive tactile stimulus (no other cognitive, perceptual or motor intervention), in a within-participant SEPs study. Spinal (N14) and subcortical (N18)
peaks remained unchanged. The parietal lobe N20 and
frontal lobe N30 cortical SEP amplitudes were increased
during anesthetic block of the ipsilateral ulnar nerve. This
anesthesia, which the authors termed transient deafferentation was induced via injection of a 2% lidocaine
solution. The amplitudes differed significantly during
anesthesia compared to baseline, and following when
anesthesia was worn off. The authors interpreted that increased peak amplitudes reflected increased activity that
may be intracortical in origin, specifically in subareas of
the somatosensory cortex. Clinicians need to be aware
that peripheral changes in sensation, may lead to amplified changes in central (cortical) activity.
Unilateral radicular pain from the C-6 nerve root level
demonstrates SEP amplitude differences compared to
both the unimpaired side and to healthy controls.76 Ten
participants with a cervical disc protrusion compressing
the C-6 nerve root, and ten healthy age matched controls
were recruited. SEPs were recorded in a between-limb,
and between-participants design. Amplitudes of peaks
N13, P14, N20, P27, N30 were all significantly amplified in the limb with the presence of pain. This suggests
J Can Chiropr Assoc 2014; 58(2)

SR Passmore, B Murphy, TD Lee

that peak enhancement can reflect a positive correlation


between the presence of pain and SEP amplitude. Tinazzi
et al.75 concluded that SEPs might be a sensitive neurophysiological tool to investigate physiopathological
changes in humans before the appearance of hard neurological (absent reflex, or motor impairment) symptoms.
The same experimental design was used earlier to examine a population with EMG evidence of chronic unilateral
carpal tunnel syndrome (Tinazzi et al., 1998).76 Identical
to the radiculopathy study, peaks N13, P14, N20, P27
were all increased in amplitude when generated from the
pathological limb compared to the healthy limb, and to an
asymptomatic healthy age-matched control group. While
all pain and function loss in patient participants impacted
the median nerve, ulnar nerve stimulation was used to generate and record the SEPs. Based on their finding Tinazzi
et al. concluded that changes associated with chronic pain
detected by peripheral nerves may cause plastic changes
that can be detected in the brainstem prior to reaching
the cortex. Limitations to both studies are the inability
to completely homogenize the onset, duration, and intensity of the symptoms in the pain-participant population.
Future research is needed to explore the possible neurophysiological quantification of unilateral pain. Studies on
clinical interventions that decrease self-reported musculoskeletal pain could utilize a pre- post-intervention SEPs
design with the predication that peaks will attenuate as
pain decreases.
The issue of standardizing pain delivered to participants has been overcome using an experimentally-induced pain model.77 Rossi et al.57 built on their foundation to understand how their induced perturbation impacted behavioural, specifically motoric and imagined
movement findings in a subsequent study. The induced
tonic hand pain using a Levo-Ascorbic solution injection in the first dorsal interosseous muscle. They found
that the N18 SEP peak was significantly increased when
the pain was present. There was a significant decrease
in N30 amplitude when asked to imagine finger movement during the pain condition. The attenuation of N30
was even more pronounced during actual motor recruitment. The strength of this study is the consideration of
neurophysiological measurement, and behavioural or
imagined movement. A weakness is that no behavioural
outcome measures were recorded to quantitatively assess
motor task performance.
J Can Chiropr Assoc 2014; 58(2)

SEPs Design (Pre and Post) and Neural


Reorganization/Neuroplasticity
SEPs when recorded at baseline and compared to SEPs
recorded following a separate perceptual, sensory or motor task reflect the neuroplasticity associated with a perceptual78 or motor task79. A pre-test and post-test experimental design can be used to avoid inadvertently masking the tactile system while utilizing the SEPs technique.
Pellicciari, Miniussi, Rossini and De Gennaro78 compared
SEP recordings in the elderly and in a young population,
pre- and post-exposure to paired-associative stimuli. In
their study paired-associative stimuli were the combination of median nerve electrical stimulation, and 20 ms
later transcranial magnetic stimulation (TMS) of the S1
region. The 20 ms time delay reflects the time needed for
the afferent signal from the Median nerve to arrive at S1.
Essentially it is the reason for the N20 latency SEPs peak.
The limitation of TMS is that it is not focal to a single
structure and is a gross activation or inhibition. While
neuroplasticity may take place in both populations with
learning, the patterns and underlying structures reflecting plastic changes may differ. This suggests possible
compensatory changes to accommodate the abilities of
the elderly population. Murphy, Haavik-Taylor, Wilson,
Oliphant, and Mathers79 used pre- and post-task SEPs as
a neurophysiological measure for plasticity related to motor output. In a within-participants design 10 individuals
had SEPs recorded at baseline, then immediately after a
20-minute repetitive-typing task. Attenuation of the N13
peak, N14-18 complex, and N30-P40 complex all occurred immediately following the typing task. Had Murphy et al.79 attempted to concurrently record SEPs while
performing the typing task, the stimulus intended to be
used to stimulate the somatosensory system may have
served as an attentional, cognitive, or peripheral perturbation to motor performance that could have masked
changes in the targeted SEP peaks. To ensure accurate
interpretation, appropriate control groups are an asset to
pre- and post-task designs.
Haavik-Taylor and Murphy1 used a pre- and post-SEPs
design to consider plasticity associated with the clinical
intervention of spinal manipulation. Prior to the intervention, in a between-participant design, 24 individuals were
pseudorandomized to receive either manipulation, or passive head motion. Only the spinal manipulation group
yielded a significant attenuation of peaks N20 and N30,
179

Somatosensory Evoked Potentials

for about 20 minutes post-manipulation. This plasticity


effect provides evidence for altered cortical somatosensory processing and sensorimotor integration following
spinal manipulation. The authors concluded that their
findings may aid in the further study of the understanding
of mechanisms for functional restoration and pain relief
following spinal manipulation. An understanding at the
mechanistic level, would aid clinicians in communicating
the clinical significance of their intervention to patients,
and colleagues from other healthcare disciplines.
A more recent somatosensory evoked potential (SEP)
study investigated patients with a history of reoccurring
neck pain or stiffness. SEPs were elicited via 3 methods.
First from the median nerve and second from the ulnar
nerve. The third method included simultaneous median
and ulnar nerve stimulation. The ratios of the individual
sum were compared to the dual simulatanous SEPs.80 In
a pre- post-task design participants had baseline SEPs recordings, performed a thumb tapping task on a single key
for 20-minutes at a rate of 180 strikes per minute, then
had post-task recordings. There was a significant increase
in the dual SEP ratio for the N20-P25 complex, and the
P22-N30 SEP cortical SEP components after a 20-minute
motor task. However this increase did not occur when the
motor training task was preceded with spinal manipulation. Spinal manipulation prior to the motor training task
actually caused a significant decrease in the dual SEP
ratio for the P22-N30 SEP component, most likely due to
changes in the ability to appropriately filter somatosensory information at the cortical level.
SEPs and Future Chiropractic Research
The future usefulness of SEPs for the chiropractor or other
manual therapists can be viewed from 2 distinct vantage
points. First, SEPs can by used to measure if changes are
present in the patient pre- compared to post-intervention.
Hypothetically, a patient with concussive symptoms of
mechanical origin may demonstrate central changes associated with a course of chiropractic intervention. A patient
with a peripheral nerve entrapment, may yield changes in
peripheral, central, or a combination of regions following
a course of care compared to baseline. There is precedent for using a pre- post- intervention SEPs design with a
clinical population. For example as mentioned in the previous section Haavik Taylor and Murphy recorded SEPs
on a population with neck pain80, they have also previ180

ously studied SEPs in patients with reoccuring neck stiffness1, and pain-free people with a history of cervical spine
issues2 pre- and post-spinal manipulation. In a recent review regarding their work related to SEPs and spinal manipulation, Haavik and Murphy hypothesize that spinal
manipulation leads to appropriate joint movement, which
in turn yields normal afferent input allowing for appropriate somatosensory processing and integration to occur.3
Second, SEPs could in the future also be used to measure
if there are changes in the clinician, either: a) with learning the motor skill of spinal manipulation delivery; or b)
if the clinician suffers an injury or pathology but is still
trying to deliver manual therapies. When measuring changes in the clinician it would be most useful to use SEPs
in tandem with a behavioural performance measure (reaction or movement time, and with kinetic or kinematic
data) in order to determine if there is a correlation between behavioural and neurophysiological measures. The
addition of behavioural measures allows for the intrepretation of not just the neurological regions impacted by
clinical intervention, but also the functional performance
differences that are possible.
Conclusion
Somatosensory evoked potential recording has been established as a meaningful neurophysiological measurement technique in both clinical and research contexts.
Specific parameters for eliciting and measuring SEPs
have been created as recommendations for uniform testing conditions. Obliteration and pathology studies have
allowed understanding of the significance and origin of
several peaks. Changes in activity resulting in peak latency and amplitude modulation allow the visualization and
quantification of precognitive neural plasticity associated
with perceptual, cognitive, and motor tasks or phenomena. SEPs have also been used to show changes with both
transient and chronic pain, and changes following spinal
manipulation. Future studies should extend the work on
altered sensory input, including pain, joint dysfunction,
paresthesia, as well as their interaction with motor training and sensory perception.
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